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A nurse on the labor and delivery unit is caring for a patient who is having induction of labor with oxytocin administered through a secondary IV line. Uterine contractions occur every 2 minutes, last 90 seconds each, and are strong to palpation. The baseline fetal heart rate is 150/min, with uniform decelerations beginning at the peak of the contraction, nadir after the peak of the contraction, and a return to baseline after the contraction is over.
Which of the following actions should the nurse take?

A.

Increase the rate of infusion of the IV oxytocin.

B.

Decrease the rate of infusion of the maintenance IV solution.

C.

Discontinue the infusion of the IV oxytocin.

D.

Slow the client's rate of breathing.

E.

Slow the client's rate of breathing.

Answer and Explanation

The Correct Answer is C

Choice A rationale

Increasing the rate of infusion of IV oxytocin in the presence of abnormal fetal heart rate decelerations is contraindicated. It may exacerbate uterine hyperstimulation, further compromising fetal oxygenation.

 

Choice B rationale

Decreasing the rate of infusion of the maintenance IV solution will not address the issue of uterine hyperstimulation or abnormal fetal heart rate decelerations. The focus should be on managing oxytocin administration.

 

Choice C rationale

Discontinuing the infusion of IV oxytocin is appropriate due to uterine tachysystole and associated fetal heart rate decelerations. This helps reduce uterine contractions and allows for fetal recovery, improving oxygenation.

 

Choice D rationale

Slowing the client's rate of breathing is not related to managing uterine contractions or fetal heart rate decelerations. The intervention should directly address the cause of the decelerations, which is oxytocin-induced hyperstimulation. .


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View Related questions

Correct Answer is B

Explanation

Choice A rationale

Prophylactic treatment for cytomegalovirus during pregnancy isn't generally recommended. CMV detection should lead to close monitoring rather than prophylactic treatment, as

current treatments pose risks without guaranteed efficacy.

Choice B rationale

Avoiding cat litter is crucial during pregnancy to prevent toxoplasmosis infection, which can cause severe fetal harm, including hydrocephalus, mental disabilities, and seizures, by

transferring through contact with cat feces.

Choice C rationale

While avoiding crowded places can reduce general infection risks, it is not specifically associated with preventing TORCH infections. TORCH infections refer to a set of perinatal infections that pose particular risks to fetal health.

Choice D rationale

Rubella immunization should be done before pregnancy, not during, as live vaccines carry risks. A woman should confirm immunity before conception to protect against congenital rubella syndrome.

Correct Answer is D

Explanation

Choice A rationale

External fetal monitors are non-invasive and do not pose a risk of transmitting HIV from mother to baby. They are considered safe for monitoring fetal well-being in an HIV-positive mother.

Choice B rationale

Administering antiviral medication is essential in reducing the risk of mother-to-child transmission of HIV. It's a standard care practice for managing HIV-positive pregnant women.

Choice C rationale

Preparing for a caesarean section may be recommended to reduce the risk of vertical transmission of HIV during delivery, especially if the viral load is high.

Choice D rationale

Internal fetal scalp electrodes are contraindicated because they can create a portal for HIV transmission from mother to baby through small abrasions or punctures on the fetal scalp.

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